Factors associated with positive attitude towards hypertension control in Hawassa city administration: Community based cross‐sectional study

Abstract Background and Aims In low‐income countries where there is shortage of appropriate medical care to manage hypertension (HTN), understanding dynamics of communities' knowledge and attitude to prevent through lifestyle is crucial. Despite this fact, there was limited information on levels of awareness and attitude towards HTN and its prevention in the study setting. So, this study was conducted to assess level and factors associated with positive attitude in Hawassa city, Southern Ethiopia. Methods A community level study using cross‐sectional design was done in Hawassa city administration in 2017. Six hundred and twelve respondents were selected using a multi‐stage sampling technique. Knowledge and attitude were assessed using multiple questions and responses were categorized considering mean as cutoff points. Descriptive statistics and binary logistic regression analysis at 95% confidence interval (CI) were performed. Results The level of mean score of knowledge was 62.7% (SD = 22.2) [95% CI: 60.9–64.4] while that of attitude was 68.1% (SD = 8.8) [95% CI: 67.4–68.8]. Divorced/widowed respondents were 73% less likely to have positive attitude as compared to married respondents (adjusted odds ratio [AOR] 95% CI: 0.27 [0.14–0.51], p‐<0.001). Respondents who attended primary, secondary and higher education were 2.84 times (AOR 95% CI: [1.48–5.42], p 0.002), 5.59 times (AOR 95% CI: [2.87–10.89], p‐<0.001) and 9.28 times (AOR 95% CI: [4.39–19.65], p‐<0.001) more likely to have positive attitude as compared to those who cannot read and write. Moreover, respondents who have good knowledge were 2.24 times (AOR 95% CI: [1.49–3.37], p‐<0.001) more likely to have positive attitude as compared with those who have poor knowledge. Conclusion The overall levels of knowledge and attitude related to HTN and its prevention were moderate but not adequate to bring lifestyle modifications required to prevent and control HTN. Health promotion activities should be strengthened to improve awareness and attitude that are pillars to bring lifestyle modification practices.

14.4%-16.9%). 10 Systematic review and meta-analysis of studies conducted on HTN in Ethiopia showed that pooled prevalence of HTN was 21.81% (95% CI: 19.20-24.42). 11 For this alarming health condition especially in low-income countries where there is shortage of appropriate medical care, understanding dynamics of communities' knowledge and attitude to prevent through lifestyle modification is crucial. 12 Despite this fact, there was limited information on levels of awareness and attitude to behavioral change in the study setting. So, this study was conducted to assess knowledge and attitude towards HTN prevention and factors associated with positive attitude in Hawassa city, Southern Ethiopia.

| METHODS
In 2017, community-based cross-sectional study was conducted in Hawassa City Administration, Sidama Region, Ethiopia. From 2005 census projection, the city had population of 351,567 in a total of eight sub-cities from which 250,777 were living in urban area and 100,790 were living in peri-urban area. The peri-urban area refers a setting which is partly urban and partly rural.
Sample size was calculated using single population formula assuming proportion of people with a positive attitude 50% (to maximize sample size), 5% margin of error, and 80% power at 95% CI.
Considering the design effect of 1.5 and after adding 10% nonresponse rate, the final sample size was 633.
To select the study participants, a multi-stage sampling technique was used. First, from eight sub-cities in the city administration, two urban and one peri-urban were selected randomly. In the second stage, a total of nine kebeles (three kebeles from each sub-city) were selected using simple random sampling. Kebeles are lowest administrative structure in the study setting. Considering population size, the calculated sample size was allocated proportionally to selected kebeles. In the third stage, households were selected randomly from lists of households in kebeles. And finally, one random adult resident from each household fulfilling inclusion criteria were included in the study.
Age of 30 years or more and residing for 6 months or more in the city were considered as inclusion criteria.
Health Belief Model (HBM) from the individual-level theories was used to assess behavior and attitude. The Health Belief Model contains concepts that predict why people will act to prevent conditions, what barriers hinder them, how do they feel like the seriousness of the condition and their susceptibility, and what promotes them to take action. The model is constructed of six blocks. These are the perceived severity/threat, perceived susceptibility, perceived benefit, perceived barriers, cues to action, and selfefficacy. 13 The questionnaire comprised socio-demographic variables,

| Knowledge about HTN and its prevention
A majority, 587 (95.9%), of participants know that HTN can cause sudden death. The lowest scores were recorded for questions on normal blood pressure, 257 (42.0%), and place where blood pressure can be measured, 248 (40.5%) ( Table 2). From the total of ten questions, the mean score was 62.7% (SD = 22.2) (95% CI: 60.9-64.4), and 325 (53.1%) respondents scored above mean and categorized as good knowledge.

| Factors associated with positive attitude
Multivariable binary logistic regression showed that marital status, educational status and overall knowledge about HTN and its prevention were associated with positive attitude at 95% CI ( Regarding marital status, respondents who divorced or widowed were 73% less likely to have positive attitude as compared to married respondents. Widowhood and divorce are significantly stressful events and are associated with psychological consequences. 18 So, this negative attitude among divorced or widowed groups could be due to psychological impacts or less chance of sharing information with partner. A study from the same country, Ethiopia, also reported that divorced or widowed groups have less odds of positive attitude towards disease control as compared to married groups. 19 In low-income countries, the awareness about HTN, its management, and control remain very low 20  Ethiopia. 23 To improve lifestyle change practices, we recommend the health system to strengthen awareness creation and bringing positive attitude.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest. All authors declare that this study is original. All authors have read and approved the final version of the manuscript. TP had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. TP affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

TRANSPARENCY STATEMENT
The lead author (Tsegab Paulose) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.